From caution to urgency: the evolution of HIV testing and counselling in Africa

Bull World Health Organ 2012;90:652–658B | doi:10.2471/BLT.11.100818 Research 652 From caution to urgency: the evolution of HIV testing and counselling in Africa R Baggaley,a B Hensen,b O Ajose,c KL Grabbe,d VJ Wong,e A Schilsky,d Y-R Lo,a F Lule,f R Granicha & J Hargreavesb Background Since the first antibody tests for human immunodeficiency virus (HIV) infection became available, public health orga- nizations and human rights activists have debated the best approach to HIV testing and counselling (HTC).1 At a time when there was no effective treatment and HIV-infected indi- viduals faced widespread discrimination and stigmatization,1 many argued that HTC was inappropriate because it provided little benefit to the individual.1,2 Conversely, others believed that testing was the key to promoting a change in behaviour.1,3 These two concerns framed early debates about HTC.4 Initially, there was general support for a cautious response to HTC and HIV infection, although this was considered “exceptional” compared with responses to other infectious diseases.1,5 For example, in 1987, the World Health Organiza- tion (WHO) emphasized caution in extending routine HIV testing beyond blood donors.1 At that time, standards for HTC, which were based on an international consensus reached by WHO and other stakeholders, emphasized voluntarism and gave rise to the adoption of voluntary counselling and test- ing.1 This approach consisted of three primary components: counselling before and after an HIV test, which included an individualized risk-reduction plan based on the test results; informed written consent; and confidentiality.1 As evidence emerged that antiretroviral therapy (ART) could significantly reduce mother-to-child HIV transmission and “alter the clinical course” of HIV infection, the HTC debate changed.1,3,6 Clinicians and public health professionals now argued that an exceptional approach to HTC was no longer appropriate. The view was that HTC should be standard clini- cal practice in settings where patients present with symptoms of an HIV infection and where ART is available.1,2 At first, however, ART was not universally available. In 2003, only 1% of individuals in need of ART had access to treatment and WHO declared a global health emergency.7 This declaration gave rise to a series of initiatives for expanding access to ART in developing countries, including the 2003 WHO 3-by-5 initiative and The World Bank’s Multi-Country HIV/AIDS Program.7–9 In the same year, increased funding for extending treatment became available through the United States President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria. In addition, the political climate changed and increased access to prevention and treatment of HIV infection was endorsed. These developments profoundly influenced the debate on HTC at a time when fewer than 10% of those infected with HIV were aware of their status10 and most were diagnosed at the end stage of the disease, when immune suppression made ART less effective.11,12 Consequently, voluntary counselling and testing was no longer seen as sufficient for enabling people to become aware of their HIV status. In the era of ART, alterna- tive approaches to HTC were required.1,2 One development was the emergence of provider-initiated HIV testing and counselling (PITC).1 In 2003, only 52% of pregnant women in Botswana knew their HIV status.13 To increase the knowledge of HIV status, the government insti- tuted a policy of “routine” PITC in various clinical settings in 2004.14 Similarly, Uganda implemented PITC in referral hospitals in 2005 and Zambia implemented it in tuberculosis Objective To describe recent changes in policy on provider-initiated testing and counselling (PITC) for human immunodeficiency virus (HIV) infection in African countries and to investigate patients’ experiences of and views about PITC. Methods A review of the published literature and of national HIV testing policies, strategic frameworks, plans and other relevant documents was carried out. Findings Of the African countries reviewed, 42 (79.2%) had adopted a PITC policy. Of the 42, all recommended PITC for the prevention of mother-to-child HIV transmission, 66.7% recommended it for tuberculosis clinics and patients, and 45.2% for sexually transmitted infection clinics. Moreover, 43.6% adopted PITC in 2005 or 2006. The literature search identified 11 studies on patients’ experiences of and views about PITC in clinical settings in Africa. The clear majority regarded PITC as acceptable. However, women in antenatal clinics were not always aware that they had the right to decline an HIV test. Conclusion Policy and practice on HIV testing and counselling in Africa has shifted from a cautious approach that emphasizes confidentiality to greater acceptance of the routine offer of HIV testing. The introduction of PITC in clinical settings has contributed to increased HIV testing in several of these settings. Most patients regard PITC as acceptable. However, other approaches are needed to reach people who do not consult health-care services. a HIV/AIDS Department, World Health Organization, Geneva, Switzerland. b Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England. c Clinton Health Access Initiative, Dar es Salaam, United Republic of Tanzania. d Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, United States of America (USA). e Office of HIV/AIDS, United States Agency for International Development, Washington, USA. f Communicable Diseases, World Health Organization Regional Office for Africa, Brazzaville, Congo. Correspondence to B Hensen (e-mail: bernadette.hensen@lshtm.ac.uk). (Submitted: 5 December 2011 – Revised version received: 9 May 2012 – Accepted: 11 May 2012 – Published online: 27 June 2012 ) Bull World Health Organ 2012;90:652–658B | doi:10.2471/BLT.11.100818 653 Research HIV testing and counselling in AfricaR Baggaley et al. clinics in 2004.15,16 In 2006, the United States Centers for Disease Control and Prevention recommended that PITC be offered to adults aged 13 to 64 years in all health-care settings, with consent be- ing assumed unless the patient explicitly declined.1,17 As treatment was scaled up, routine HTC gained traction and several countries introduced PITC in clinical settings. Early results demonstrated an increase in HTC uptake.18–20 With the implementation of PITC expanding globally, WHO recognized the need for guidance. In 2007, WHO and the United Nations Programme on HIV/AIDS issued a document on PITC in health- care facilities. The final document was an extensive revision of an initial 2006 draft and took into account concerns about coercion, human rights and the definition of the word “routine”.1,7 The primary aim of this study was to review how policy in African countries has changed in response to the growing recognition that health-care providers should offer more HTC. The rationale for focusing on HTC policy in Africa was, first, that 68% of the estimated 34 million people with HIV infections worldwide at the end of 2010 resided in sub-Saharan Africa, a region with only 12% of the global population,21 and, second, that it was important to examine policy responses in settings where there was an urgent need to ad- dress low HTC coverage, for example, to prevent mother-to-child HIV trans- mission or to identify individuals with HIV infections who could benefit from ART. Additional aims were to investigate patients’ perceptions of PITC and their experience of the process of PITC, with particular reference to informed consent and counselling. Methods National policy documents, strategies, plans, frameworks, guidelines and re- ports on HIV testing or HIV prevention and treatment were identified by search- ing the WHO Library Information Sys- tem, Google Scholar and the knowledge base repositories of organizations and institutions, including the International Labour Organization, the United States Agency for International Development (the AIDSTAR One project), the Uni- versity of California in San Francisco (the HIVInSite knowledge base) and Harvard University. The Evidence to Ac- tion HIV and AIDS Data Hub was also searched. Where information was not readily available or further clarification was required, WHO country represen- tatives were contacted. In addition, the review also considered documents that did not focus on HIV prevention alone but covered relevant broad issues, such as maternal and child health, human rights, tuberculosis and opportunistic infections. Identified documents were grouped into three categories according to their overall objectives: • guidelines, manuals, protocols, legis- lation and policy; • national strategic plans, strate- gic frameworks and multisectoral frameworks; • other literature, including published and unpublished reviews. The date assumed for the adoption of a policy depended largely on the type of documents identified and the strength of the evidence available, with further confirmation being obtained from WHO country representatives. Since the date of publication of legislation, policy, guidelines, manuals and protocols (i.e. the first document category) explicitly indicated the date on which a policy was adopted, this date was used in preference to the dates of other documents. When these documents were not available, the publication date of a strategic plan (i.e. the second document category) was used. However, when the only docu- ments identified belonged to the third category, the date on which a policy was adopted was determined by consultation with WHO country representatives. To obtain information on patients’ experiences of and views about PITC, we searched the MEDLINE, EMBASE, International Bibliography of the Social Sciences, PsychINFO and Global Health databases for relevant documents pub- lished in 2000 or later using the follow- ing terms: provider-initiated, routine, diagnostic, opt-out, HIV, human im- munodeficiency virus, AIDS, acquired immune deficiency syndrome, coun- selling, testing, screening, experience, personal experience, opinion, attitude, acceptability and informed consent. We considered publications from a range of disciplines, with a focus on quantitative and qualitative studies of PITC. Reports of studies were reviewed if the studies: (i) involved the routine offer of HTC in an African country; (ii) were conducted in a clinical setting after HTC had been offered to patients or involved patients who were recruited in a clinical setting and had experience of PITC in that clinical setting; or (iii) assessed the ac- ceptability of PITC to patients or their experience with components of the PITC process, particularly the acquisi- tion of informed consent; and (iv) were published in English. Data on the ac- ceptability of PITC and on patients’ experiences of PITC were extracted separately. Results The policies, guidelines or strategic plans on PITC from 52 African coun- tries were reviewed. Documents for one country could not be retrieved and Western Sahara was not included in the review. There was evidence that a policy had been adopted by 42 (79.2%) of 53 countries (Table 1), whereas 10 (18.9%) had not adopted a policy: Algeria, Angola, Chad, Egypt, Libya, Morocco, the Niger, Sao Tome and Principe and Tunisia (Fig. 1). Documents could not be retrieved for the Gambia. A large proportion of countries (n = 17; 43.6%) adopted a PITC policy between 2005 and 2006, whereas 10 (25.6%) adopted a policy between 2003 and 2004 and 10 (25.6%), including the Comoros, the Congo, the Democratic Republic of the Congo and South Africa, adopted a policy between 2007 and 2008. The Central African Republic and Equatorial Guinea were the last of the 42 countries to adopt PITC, in 2009 and 2010, respectively (Table 1). Clinical settings and target populations All 42 countries that adopted a PITC policy recommended that pregnant women should be covered either in an- tenatal clinics or in services provided for the prevention of mother-to-child HIV transmission. In addition, 73.8% of the 42 countries adopted a policy of univer- sal PITC, which was defined as offering HTC to all patients or adults visiting a health-care facility. Documents for 66.7% of countries recommended PITC for either tuberculosis patients or clin- ics, 45.2% recommended it for patients with sexually transmitted infections, 14.3% for family planning clinics, 7.1% for most-at-risk populations and 7.1% for individuals attending out-patient departments (Table 1). Bull World Health Organ 2012;90:652–658B | doi:10.2471/BLT.11.100818654 Research HIV testing and counselling in Africa R Baggaley et al. Patient’s perspectives and experience The literature search identified over 2000 publications, of which 11 were considered eligible for inclusion in the review (Table 2 and Table 3, avail- able at: http://www.who.int/bulletin/ volumes/90/9/11-100818). The ma9- jority were observational studies; 8 investigated the acceptability of PITC to women or their experiences of it in antenatal clinics, whereas the remaining 3 involved tuberculosis patients, women attending immunization clinics with their infants and patients attending a medical emergency unit. Overall, the large majority of in- dividuals who received PITC found it acceptable (Table 2). For example, in Uganda 98.5% of women who were at- tending an antenatal clinic for the first time considered the routine offer of HTC during pregnancy “good” or “very good”.26 In South Africa, 93% of women offered HTC while attending midwife obstetric units agreed that all pregnant women should be tested for HIV.22 Among pregnant women who opted for HTC in a study from Zimbabwe, 89% stated that the routine offer of HTC was helpful and empowering and enabled women to make an informed decision about the prevention of mother-to-child HIV transmission and infant feeding.24 In addition, experience of PITC was generally regarded as good (Table 3). For example, in Zimbabwe, 98% of pregnant women stated they were satisfied with the information they received on routine HTC.24 In South Africa, 52% of pregnant women who had been tested for HIV felt they had made an informed choice and had a positive experience, whereas 28% felt that their choice had been “less clear” and 20% that their voluntariness had been compromised.31 Discussion This review of HTC policy in Africa illus- trates the changing response to HTC that has taken place in the last decade. Before WHO issued guidance on PITC in 2007, approximately 50% of African coun- tries had adopted PITC in health-care facilities.3,33,34 Subsequently, the number of countries that included PITC in their HIV policies or strategies increased and, by the time of writing, 42 African coun- tries had elected to recommend PITC in health-care facilities, with a large propor- tion adopting such a policy between 2005 and 2006. With evidence that ART can reduce mother-to-child HIV transmis- sion, all these countries recommended PITC in antenatal clinics. In addition, more than half recommended universal coverage for all adults and coverage for tuberculosis clinics and patients. Previous studies of the acceptability of PITC have used the uptake of test- ing as an indicator of acceptability.35,36 Although they provided evidence of the feasibility of PITC, these studies did not reflect patients’ experiences of or views about PITC. Our review of the published literature suggests that PITC is generally acceptable to patients. Studies reported that more than 75% regarded PITC as acceptable, particularly in antenatal clinics.22 However, findings from studies of pregnant women may not be general- izable to other population groups since these women may be more willing to un- dergo HIV testing because they believe it will benefit their children.37 Patients in other clinical settings may find PITC less acceptable, perhaps because of their perceived risk of infection or fear.37 In our review, evidence from four studies, the majority involving small groups of pregnant women, indicated that patients were not always aware they had the right to decline HTC in antenatal clinics, perhaps because of the power balance between patients and health-care pro- viders.29,31 However, studies in other regions suggest that women may find the routine offer of HTC acceptable because it “normalizes” the process of HTC.38 Our review has several limitations. It was difficult to retrieve all the docu- ments required to understand national PITC policy fully. Although we con- Table 1. Provider-initiated HIV testing and counselling in African countries, 2003–2010 Details of PITC policy Countries No. (%) Policy adopted Yes 42 (79.2) No 10 (18.9) No information 1 (1.9) Total 53 (100) Year policy adopteda 2003 or 2004 10 (25.6) 2005 or 2006 17 (43.6) 2007 or 2008 10 (25.6) 2009 or 2010 2 (5.1) Total 39 (100) Document detailing PITC policy National policy document 35 (83.3) National strategic plan (excluding national policy documents) 7 (16.7) Total 42 (100) Clinical services or settings in which PITC was offeredb Pregnant women attending antenatal clinics or PMTCT services 42 (100) All patients or all adults visiting a health-care facility 31 (73.8) Tuberculosis clinics or patients 28 (66.7) Sexually transmitted infection clinics or patients 19 (45.2) Family planning services 6 (14.3) Inpatients (adult or paediatric) 4 (9.5) Infants of HIV-positive mothers 4 (9.5) Most-at-risk populations (e.g. men who have sex with men, injecting drug users, female sex workers and commercial sex workers) 3 (7.1) Outpatient departments 3 (7.1) Therapeutic feeding centres or children with malnutrition 2 (4.8) Psychiatric services 1 (2.4) Male circumcision services 1 (2.4) HIV, human immunodeficiency virus; PITC, provider-initiated HIV testing and counselling; PMTCT, prevention of mother-to-child HIV transmission. a The date the policy was adopted could not be determined for three countries. b The total exceeds 100% as some countries adopted PITC for more than one target population. Bull World Health Organ 2012;90:652–658B | doi:10.2471/BLT.11.100818 655 Research HIV testing and counselling in AfricaR Baggaley et al. tacted WHO country offices, it was not possible to obtain information for some countries and, for others, the date on which policy was adopted was unknown. In addition, the ambiguous language of some documents made it difficult to determine when and in which settings policies were adopted. Consequently, our data on the years in which PITC policies were adopted may be inaccurate. We minimized this inaccuracy by asking two reviewers to determine indepen- dently the date of policy adoption using the available evidence. Our review of patients’ experiences of and views about PITC also has several limitations and the findings must be interpreted with caution. First, our review was subject to a language bias and a publication bias. Second, the majority of studies included took place in antenatal clinics and there may be studies from other clinical settings that we did not identify. Some studies that reported on the ac- ceptability of PITC included only small samples of women and did not involve interviews with women who declined an offer of HTC.28,31,32 In addition, the stud- ies included in our review are subject to their own limitations: the majority were nonrandomized studies and the difficulty of reporting and synthesizing evidence from nonrandomized studies is well documented.39 Moreover, studies were subject to acquiescence bias40 and, as the questions posed to patients were different in each study, it was difficult to compare their findings. In general, the evidence suggests that the introduction of PITC in ante- natal clinics has been associated with an increase in HIV testing rates. A 2010 WHO report on universal access stated that the testing rate in eastern and south- ern Africa rose from 48% in 2008 to 50% in 2009.10 Moreover, with the increased uptake of HTC and the better access to ART that followed from the introduc- tion of PITC,13 mother-to-child HIV transmission has been virtually elimi- nated in some countries:13,24 in 2009, four of the 25 countries with the highest HIV disease burden achieved the target set by the United Nations General As- sembly Special Session on HIV/AIDS of providing at least 80% of HIV-infected pregnant women with ART.10 In addi- tion, one literature review found that the introduction of PITC in antenatal clinics contributed to the achievement of universal HTC in pregnant women.41 Moreover, the results of the seven Afri- can-based studies included in our review indicate that implementation of PITC led to an increase in the uptake of HTC by pregnant women that ranged from 9.9% in Malawi to 65.6% in Uganda, with more than 75% of women accepting PITC across all seven studies.41 The implementation of PITC has also led to a high rate of HIV testing among individuals visiting tuberculo- sis and sexually transmitted infection clinics.15,42–44 A cluster randomized trial conducted in tuberculosis clinics in South Africa in 2005 found that the introduction of opt-out PITC increased the uptake of HIV testing by 13.7%, from 6.5% when HIV testing was carried out on an opt-in basis to 20.2% with opt-out PITC.45 The 2011 WHO report on global tuberculosis control stated that HTC is now standard for tuberculosis patients in many countries, especially in Africa. In 2010, more than 75% of tuberculosis patients knew their HIV status in 68 countries and territories, including 22 countries in the WHO African Region.46 Further efforts are still needed globally, however, since only 34% of 6.2 million tuberculosis patients were aware of their HIV status in 2010. Despite the availability of effective therapy and the increase in HIV testing, population-based surveys conducted be- tween 2007 and 2009 in 10 sub-Saharan African countries indicated that the me- dian proportion of people with an HIV infection who are aware of their status was under 40%.10,47 Moreover, although PITC can contribute to increased test- ing in clinical settings,41 the adoption of PITC alone will not achieve universal access to HTC. Other approaches that enable people not attending health-care services to access HIV testing should be developed in parallel to ensure that access to testing is equitable and that in- dividuals with HIV infections are diag- nosed before they become symptomatic. In 2011, the HIV Prevention Trials Net- work study 52 (HPTN052) confirmed that ART was effective for preventing the transmission of HIV in serodiscordant Fig. 1. Adoption of a policy on provider-initiated HIV testing and counselling, Africa, 2003–2010 2003–2004 2005–2006 2007–2008 2009–2010 Date of PITC policy adoption not identified PITC policy not adopted Data not available Year PITC policy was adopted HIV, human immunodeficiency virus; PITC, provider-initiated HIV testing and counselling. Bull World Health Organ 2012;90:652–658B | doi:10.2471/BLT.11.100818656 Research HIV testing and counselling in Africa R Baggaley et al. couples.48 There is a rationale, therefore, for considering and evaluating house- hold or community-based testing in addition to expanding PITC.49 Data on these alternative approaches would help identify the most effective and appropri- ate way of implementing HIV testing in specific local contexts, while taking into account the resources available and social constraints. ■ Acknowledgements We would like to thank Chris Grundy for Fig. 1. Competing interests: None declared. 摘要 从谨慎到紧迫：非洲的艾滋病检测咨询的演变 目的 描述非洲各国最近在艾滋病毒（HIV）感染的医务人 员主动提供检测咨询（PITC）政策方面的变化，并调查病 人有关PITC的体验和看法。 方法 审查已发表的文献和国家HIV检测的政策、战略框 架、计划和其他有关文件。 结果 在审查的个非洲国家中，有42 个（79.2%）国家已经 采用了PITC政策。在这42 个国家当中，所有国家都推荐 PITC用于预防母婴HIV传播，66.7%的国家推荐用于结核 病诊所和患者，45.2%的国家推荐用于性传播感染诊所。 此外，43.6%的国家在2005 年或2006 年采用PITC。文 献检索确定了11 项有关病人对非洲诊所背景中PITC的体 验和看法的研究。绝大多数人认为PITC是可接受的。然 而，在产前诊所的妇女并不总是知道她们有拒绝接受HIV 检测的权利。 结论 非洲HIV检测咨询的政策和实践已经从强调保密的 谨慎态度转变为具有更大接受程度的常规HIV检测。在诊 所背景中引进PITC有利于在多个这样的背景中增加HIV检 测。大多数患者认为PITC是可以接受的。然而，还需要其 他方法让没到医院看病的人也能被覆盖到。 Résumé De la prudence à l’urgence: l’évolution des activités de conseil et de dépistage du VIH en Afrique Objectif Décrire les changements récents dans la politique d’activités de conseil et de dépistage à l’initiative du fournisseur (PITC), du virus de l’immunodéficience humaine (VIH) dans les pays africains, et enquêter sur les expériences et opinions des patients relatives à la PITC. Méthodes Les publications, ainsi que les politiques nationales, les cadres stratégiques, les plans et autres documents pertinents relatifs au dépistage du VIH ont été étudiés. Résultats Sur les pays africains passés en revue, 42 d’entre eux (79.2%) avaient adopté une PITC. Sur ces 42 pays, tous recommandaient la PITC pour la prévention de la transmission mère-enfant du VIH, 66,7% pour les cliniques soignant la tuberculose et les patients affectés par cette maladie, et 45,2%, pour les cliniques soignant les infections sexuellement transmissibles. En outre, 43,6% des pays avaient adopté la PITC en 2005 ou 2006. L’examen des publications a permis d’identifier 11 études sur les expériences des patients et leur opinion relatives à la PITC dans les environnements cliniques en Afrique. La grande majorité considérait la PITC comme étant acceptable. Cependant, les femmes en consultations prénatales n’étaient pas toujours conscientes du fait qu’elles avaient le droit de refuser un dépistage du VIH. Conclusion La politique et la pratique relatives aux activités de conseil et de dépistage du VIH en Afrique sont passées d’une approche prudente, mettant l’accent sur la confidentialité, à une plus grande acceptation de l’offre systématique de dépistage du VIH. L’introduction de la PITC dans les milieux cliniques a contribué à augmenter le dépistage du VIH dans plusieurs de ces environnements. La plupart des patients considèrent la PITC comme étant acceptable. Toutefois, d’autres approches sont nécessaires pour atteindre les personnes qui ne font pas appel aux services de santé. صخلم ايقيرفإ في يشربلا يعانلما زوعلا سويرف نأشب ةيعوتلاو رابتخلاا روطت :ةحللما ةجالحا لىإ رذلحا نم رابتخلااب ةصالخا ةسايسلا في ةيرخلأا تايرغتلا فصو ضرغلا ىودع نأشب )PITC( تامدلخا يمدقم نم ةردابمب ةيعوتلاو يرتحو ةيقيرفلأا نادلبلا في )HIV( يشربلا يعانلما زوعلا سويرف يمدقم نم ةردابمب ةيعوتلاو رابتخلاا لوح ضىرلما ءارآو براتج .تامدلخا ةينطولا تاسايسلاو ةروشنلما داوملل ةعجارم ءارجإ مت ةقيرطلا ،ةيجيتاترسلإا رطلأاو ،يشربلا يعانلما زوعلا سويرف تارابتخلا .ةلصلا تاذ ىرخلأا تادنتسلماو ططلخاو اًدلب 42 دمتعا ،ضارعتسلال تعضخ اًيقيرفأ اًدلب ينب نم جئاتنلا .تامدلخا يمدقم نم ةردابمب ةيعوتلاو رابتخلاا ةسايس )79.2%( ةيعوتلاو رابتخلااب اهلك ينعبرلأاو يننثلاا نادلبلا تصوأ دقو زوعلا سويرف لاقتنا عنلم كلذو تامدلخا يمدقم نم ةردابمب اهنم % 66.7 ةبسن تصوأو ،لفطلا لىإ ملأا نم يشربلا يعانلما % 45.2 ةبسن تصوأو ،لسلا ضىرمو تادايعل ةسايسلا هذبه ،كلذ لىع ةولاع .ًايسنج ةلوقنلما ىودعلا تادايع عم اهمادختساب يمدقم نم ةردابمب ةيعوتلاو رابتخلاا % 43.6 ةبسن تدمتعا داولما في ثحبلا ددحو .2006 وأ 2005 يماع في تامدلخا رابتخلاا نأشب ضىرلما ءارآو براتج لوح ةسارد 11 ةروشنلما في تادايعلا عقاوم في تامدلخا يمدقم نم ةردابمب ةيعوتلاو ةردابمب ةيعوتلاو رابتخلاا نأ ةحضاو ةيبلغأ تبرتعا دقو .ايقيرفإ تادايع في ءاسنلا نإف ،كلذ عمو .لوبقم تامدلخا يمدقم نم رابتخا ءارجإ ضفر في نهقحب ةيارد لىع ًمئاد ّنكي لم لملحا ةياعر .يشربلا يعانلما زوعلا سويرف ةيعوتلاو رابتخلااب ةصالخا ةسرملماو ةسايسلا تلوتح جاتنتسلاا دكؤي رذح جنه نم ايقيرفإ في يشربلا يعانلما زوعلا سويرف نأشب سويرف رابتخا ءارجلإ يدايتعلاا جهنلل بركأ لوبق لىإ ةيسرلا لىع ةردابمب ةيعوتلاو رابتخلاا ميدقت مهاس دقو .يشربلا يعانلما زوعلا تارابتخا ددع ةدايز في تادايعلا عقاوم في تامدلخا يمدقم نم برتعاو .عقاولما هذه نم ديدعلا في يشربلا يعانلما زوعلا سويرف تامدلخا يمدقم نم ةردابمب ةيعوتلاو رابتخلاا نأ ضىرلما مظعم لىإ لوصولل ىرخأ ج ُهنه لىإ ةجاح كانه ،كلذ عمو .لوبقم رمأ .ةيحصلا ةياعرلا تامدخ لىإ نوئجلي لا نيذلا صاخشلأا Bull World Health Organ 2012;90:652–658B | doi:10.2471/BLT.11.100818 657 Research HIV testing and counselling in AfricaR Baggaley et al. Резюме От предупреждения к необходимости: развитие консультирования и тестирования на ВИЧ в Африке Задача Описать недавние изменения в стратегии тестирования и консультирования по инфекции вируса иммунодефицита человека (ВИЧ), проводимого по инициативе медицинских работников (PITC) в африканских странах, и исследовать опыт и отношение пациентов к PITC. Методы Был проведен обзор опубликованной литературы и национальных стратегий тестирования на ВИЧ, основных схем оперативной деятельности, планов и других соответствующих документов. Результаты Из рассмотренных африканских стран, в 42 (79.2%) странах была принята стратегия PITC. Из 42 стран, всеми рекомендована PITC для профилактики передачи ВИЧ от матери к ребенку, 66,7% рекомендовали стратегию для туберкулезных больниц и пациентов, страдающих туберкулезом, и 45,2% - для больниц, специализирующихся на инфекционных заболеваниях, передающихся половым путем. Кроме того, 43,6% приняли PITC в 2005-2006 гг. Благодаря информационному поиску, было определено 11 исследований, посвященных опыту и отношению пациентов к PITC в условиях клинической практики в Африке. Явное большинство считало PITC приемлемой. Впрочем, женщины в клиниках дородового наблюдения не во всех случаях знали о своем праве на непрохождение теста на ВИЧ. Вывод Стратегия и практика по консультированию и тестированию на ВИЧ в Африке изменилась с продуманного подхода, акцентированного на конфиденциальности, к большему принятию предложений о тестировании на ВИЧ в целях профилактики. Внедрение PITC в клиническую практику привело к увеличению числа тестов на ВИЧ в некоторых учреждениях. Большинство пациентов считают PITC приемлемой. Однако необходимо выработать другие подходы для людей, которые не пользуются услугами здравоохранения. Resumen De la cautela a la urgencia: La evolución de las pruebas de detección del VIH y el asesoramiento en África Objetivo Describir los cambios recientes en la estrategia sobre la realización de pruebas de detección del virus de la inmunodeficiencia humana (VIH) y el asesoramiento emprendidos por los proveedores (PITC) en países africanos e investigar las experiencias de los pacientes y sus opiniones acerca de la PITC. Métodos Se llevó a cabo un examen de las publicaciones y de estrategias de detección del VIH nacionales, convenios estratégicos, planes y otros documentos importantes. Resultados De los países africanos examinados, 42 (79,2%) había adoptado la estrategia PITC. De esos 42, todos recomendaban la PITC para prevenir la transmisión maternoinfantil del VIH, el 66,7% la recomendaba a las clínicas y pacientes con tuberculosis y el 42,5% a las clínicas de tratamiento de infecciones de transmisión sexual. Además, el 43,6% adoptó la PITC en el año 2005 o 2006. La búsqueda bibliográfica identificó 11 estudios sobre las experiencias de los pacientes y sus opiniones acerca de la PITC en entornos clínicos de África. Una mayoría clara consideró la PICT aceptable. Sin embargo, las mujeres en las clínicas de atención prenatal no siempre fueron conscientes de que tenían el derecho a rechazar las pruebas de detección del VIH. Conclusión La estrategia y práctica de las pruebas de detección del VIH y el asesoramiento en África han cambiado desde un enfoque cauteloso que enfatiza la confidencialidad a una mayor aceptación de la oferta sistemática de pruebas de detección del VIH. La introducción de la PITC en los entornos clínicos ha contribuido a incrementar el número de pruebas de detección del VIH en muchos de esos entornos. La mayoría de pacientes considera la PTIC aceptable. No obstante, se necesitan otros enfoques para llegar a aquellas personas que no acuden a los servicios sanitarios. References 1. Bayer R, Edington C. 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Increasing access to HIV counseling and testing through mobile services in Kenya: strategies, utilization, and cost-effectiveness. J Acquir Immune Defic Syndr 2010;54:317–23. doi:10.1097/QAI.0b013e3181ced126 PMID:20453819 Bull World Health Organ 2012;90:652–658B | doi:10.2471/BLT.11.100818 658A Research HIV testing and counselling in AfricaR Baggaley et al. Table 2. Acceptability of provider-initiated HIV testing and counselling, Africa, 1999–2009 Publication (Author, year) Country Primary objective Sample size Population group Acceptability Etiebet, 200422 South Africa Knowledge, attitude and practices survey of women receiving prenatal or postnatal care 264 Women attending midwife obstetric units (i) 93% agreed that all pregnant women should be tested for HIV; (ii) 98% agreed they would recommend attendance at a clinic that routinely offers HIV testing to a friend or sister Nakanjako, 200723 Uganda To determine whether patients would accept a routine offer of HIV testing in a medical emergency setting 233 Adult patients (i) 99% expressed a need to integrate routine HTC into medical care at the emergency unit; (ii) 86% believed routine testing would help link HIV-positive patients to HIV care services Chandisarewa, 200724 Zimbabwe To assess the impact of routine ANC testing for PMTCT 221 Follow-up survey with pregnant women (i) 89.1% stated that offering routine testing was helpful as it empowers women to “exercise their rights and responsibilities” with regard to accessing relevant information and making informed choices about PMTCT; (ii) 10.9% stated that the offer of routine antenatal testing was not helpful Corneli, 200825 Democratic Republic of the Congo To identify an acceptable approach to HIV testing for tuberculosis patients based on the views of patients and health- care workers 88 Tuberculosis patients (i) 99% supported the incorporation of HIV testing into routine care for tuberculosis patients; (ii) 99% expressed the view that HIV testing should be offered at the start of tuberculosis treatment; (iii) 68% preferred HIV testing to be offered by a tuberculosis nurse (including 93% of tuberculosis patients who were tested in this way); (iv) 24% preferred referral to on-site HIV testing; (v) 8% preferred referral to a freestanding voluntary HTC site Byamugisha, 200926 Uganda To assess attitudes towards routine HIV testing among new ANC attendees 388 First-time ANC attendees Question posed: “Nowadays in this clinic all mothers are tested for HIV unless they say no, what do you think about this system?” 98.5% responded “good” or “very good (helps them know their HIV status and thus plan for their future and that of their baby)”; 1.5% responded “fair”, “bad” or “very bad” Rollins, 200927 South Africa To determine the acceptability and feasibility of universal HIV testing of 6-week- old infants attending immunization clinics 646 Women with infants (i) Question posed: “How did you feel when offered the opportunity of HIV testing?” (for infants). Response: 77.9% comfortable; 11% surprised; 4.5% frightened; 3.4% shocked; 1.5% anxious; 0.3% preferred not to answer; 0.2% other; (ii) 89.8% would recommend HTC to “others” Angotti, 201028 Malawi To determine local perceptions of routine HIV testing and the potential consequences 18 (12 from an ANC attendee sample) Women who had been offered HTC in an ANC and accepted Interviewees made “favourable” comments about the routine offer of HTC and generally accepted its implementation in an ANC Larsson, 201129 Uganda To explore women’s experiences of, and views on, the opt-out testing policy and associated HIV testing in an ANC 18 Pregnant women attending an ANC Some women viewed the opt-out testing policy as positive as it could benefit their child and themselves ANC, antenatal clinic; HIV, human immunodeficiency virus; HTC, HIV testing and counselling; PMTCT, prevention of mother-to-child HIV transmission. Bull World Health Organ 2012;90:652–658B | doi:10.2471/BLT.11.100818658B Research HIV testing and counselling in Africa R Baggaley et al. Table 3. Users’ experiences of provider-initiated HIV testing and counselling, Africa, 1999–2009 Publication (Author, year) Country Primary objective Sample size Population group Experience Etiebet, 200422 South Africa Knowledge, attitude and practices survey of women receiving prenatal or postnatal care 264 Pregnant women (i) 94% were satisfied with the counselling services offered to them; (ii) 0.34% felt pressured by nurses to accept testing (45% believed that women who accepted testing receive better care); (iii) 8% of women tested did not remember receiving post-test counselling Chandisarewa, 200724 Zimbabwe To assess the impact of routine ANC testing for PMTCT 2011 Exist survey with pregnant women 98% stated that the information provided by counsellors on routine testing had “adequately prepared” them for the result Corneli, 200825 Democratic Republic of the Congo To identify an acceptable approach to HIV testing for tuberculosis patients based on the views of patients and health-care workers 88 Tuberculosis patients (i) The majority (71%) felt confident they had the right to choose whether or not to be tested; (ii) 29% believed it would be difficult to decline a routine offer of testing from a nurse and some said this was because of the power relationship whereas others felt it was because health-care workers know what is best for them Mugore, 200830 Zimbabwe To assess understanding of a routine offer of HTC among women attending ANC 146 Pregnant women (i) 95% stated that the information they received during group education was sufficient to make a decision about whether or not to test for HIV; (ii) 94.1% knew their blood was being drawn for HTC; (iii) 77.8% of those who declined HTC said it would not deter them from seeking ANC at the health facility Byamugisha, 200926 Uganda To assess attitudes towards routine HIV testing among new ANC attendees 388 First time ANC attendees (i) 90.2% had a “good” or “very good” experience with or opinion of the health education talk, whereas 9.8% had a “fair”, “bad” or “very bad” experience; (ii) 86.3% had a “good” or “very good” experience with or opinion of pretest counselling, whereas 13.7% had a “fair”, “bad” or “very bad” experience; (iii) 95.1% had a “good” or “very good” experience with or opinion of post-test counselling, whereas 4.9% had a “fair”, “bad” or “very bad” experience Groves, 201031 South Africa To evaluate women’s experiences with HTC 25 Women who had been tested for HIV during their most recent pregnancy (i) 52% believed they had clearly consented to testing and had a positive experience of group and individual education sessions; (ii) 28% said their choice was “less clear” and were less positive about the education sessions; (iii) 20% felt their choice had been compromised (48% of these women expressed the view that they experienced less autonomy in deciding whether to be tested for HIV) Angotti, 201028 Malawi To determine local perceptions of routine HIV testing and the potential consequences 18 (12 from an ANC attendee sample) Women that had been offered HTC in an ANC and accepted the offer (i) 22.2% stated that refusing the offer of a test was an option and believed that women could still receive services if they opted out of testing; (ii) the majority who underwent HIV testing stated they were not given the option of refusing in the ANC; (iii) HTC was considered a precondition for receiving care Larsson, 201129 Uganda To explore women’s experiences of, and views on, the opt- out testing policy and associated HIV testing in an ANC 18 Pregnant women attending an ANC (i) Pregnant women recruited from facilities that offered testing on site perceived HIV testing as compulsory, despite pretest group counselling; (ii) generally women thought they could not receive any other ANC service if they declined testing; (iii) women felt obligated to attempt to persuade their partners to attend the ANC for HIV testing and felt anxious about asking their male partners to participate in couples testing; (iv) women highlighted the power asymmetry between themselves and health-care providers Ujiji, 201132 Kenya To identify factors associated with consent to opt-out of HTC 900 Pregnant women (i) 17% understood that HIV testing was optional, whereas 83% did not; (ii) when asked: “If you could choose to HIV test or not, would you decline?”, 80% responded “no” and 20% responded “yes” ANC, antenatal clinic; HIV, human immunodeficiency virus; HTC, HIV testing and counselling; PMTCT, prevention of mother-to-child HIV transmission.